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Bloomberg News Article: "Doctors’ profit may dictate prostate cancer treatment"

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Posted 10/25/2013 12:37 PM (GMT -5)
"Urologists who buy their own equipment to provide expensive radiation treatment are more likely to use it to treat prostate cancer even when the benefit for patients is unclear, research shows."

www.bostonglobe.com/news/science/2013/10/24/prostate-cancer-radiation-therapy-rises-when-doctors-own-machine/2vyyazgtyvtZvTUHY6VUVK/story.html

All of my PCa treatment has been at a university medical center, so being treated by doctors who own their own radiology equipment hasn't been my personal experience. But I saw this article this morning and thought it worth sharing.
Posted 10/25/2013 2:59 PM (GMT -5)
Well, I gotta believe the dozen or so facilities that offer proton therapy are going to fight back on the new guidelines that no longer recommend proton, a corollary to this article that one tries to leverage their investment.

Back to the article, that's why I am a big proponent of having a team of 2 surgeon/s urologists, one radiation oncologist and quarterbacked by a medical oncologist in order the flesh out their various biases.

To do this, they should not all be from the same practice to avoid the issues with self referrals.

LupronJim
Posted 10/25/2013 4:19 PM (GMT -5)
We do have to go into this as a thinking adults. As such, you need to give treatment options the smell test, and particularly with PCa, carefully question the motives of anyone who wants to rush you into any course of action. This is, of course, difficult in the face of "diagnosis shock" especially if you don't acknowledge that your doctor's kids' tuition bills could just possibly influence the things your doctor suggests.

Certainly sounds like a classic case of "when the only tool you have is a hammer, everything starts to look like a nail" with an extra dose of profit motive and exploitation.

That's also a terribly math-ignorant reporter - coming up with a percentage from "number of new diagnoses this year" with "number of deaths this year" (approximately none of which will be from diagnoses this year, but you wouldn't think so from reading this article...sloppy reportage indeed.)
Posted 10/25/2013 4:53 PM (GMT -5)
I am shocked! Shocked, I tell you. Imagine... doctors are in it for the money! tongue

This should not come as a surprise to any of us.

Don

Posted 10/27/2013 10:38 PM (GMT -5)
Hi Bohemond,

Thanks for the post and the link to the article. You mentioned that you had all your PCa treatment at a university medical center. Which I presume included your surgery in 2002 and your SRT in 2010.

Did you have SRT at Dana-Farber/Brighman-Women?

I ask this, because I am considering RT, and since you are from Massachusetts, I thought that you might have had treatment there. If you did, it would be great if you could share your experience.

All the best,

Joe.
Posted 10/27/2013 11:20 PM (GMT -5)
There is a lot of this going on. Unfortunately.

This is why patients need education before they get tested. It is important to understand that a referral to an in house option is not to be confused with a second opinion. Even though it's a urologist, then a radiation oncologist, it would be wise to get a urologist opinion confirmed by a different urologist not associated in any way. Then get a radiation oncologist opinion not associated with the urologist. Then get another radiologist opinion not associated with either.

It's a pain, but it's the best way to not get a financially biased opinion. This is very much a known problem. Urologists that have bought their own equipment for radiation therapy stand to make even more than if they were the treaters. and the is a direct conflict of interest.

m.medicalxpress.com/news/2013-10-docs-vested-prostate-cancer.html
m.medicalxpress.com/news/2013-10-nejm-exposes-overuse-therapy-urologists.html

Tony
Posted 10/27/2013 11:57 PM (GMT -5)

Somebody said...
Did you have SRT at Dana-Farber/Brighman-Women?


Hi Joe,

No. I was at UMass Medical Center, Worcester. I've got nothing but good things to say about my treatment at UMass over the years, including things other than my PCa treatments (a couple of urgent care and emergency room visits - my wife's hand surgery, my mother-in-law's in-hospital and hospice care for multiple health issues toward her end of life). However I know others who have been at Dana-Farber/ Brighman-Women, with excellent reports about their care, though not for PCa. Also, FWIW, my daughter was treated at Mass General Hospital for a rare and life-threatening condition (Thorasic Outlet Syndrome) by one of the world's reigning experts on this rare condition and I have nothing but praise for the team she had at MGH -- though I can't extrapolate to their results with PCa. In my daughter's case she described her symptoms over the phone, which her local doctor said were no big deal, and the doc at MGH told her to get there "now." He stayed late to see her that evening and immediately admitted her for emergency treatment, followed by surgery a month later. I have to say that here in Massachusetts, we have a concentration of teaching hospitals and medical schools that is hard to match in most places in the world. But even so, we have to do our homework on the individual doctors and their range of expertise.

If you want to talk privately about doctor names, etc., my email address is in my my profile. I'm very happy with my RO at UMass, but then I may have just got lucky. I'm now approaching 4 years since my SRT, but now see him annually and will see him again in Jan. Given that I am--however improbably--still in remission, I prefer to see him annually for a reality check and also to keep him on-board as someone whose opinion I respect, in addition to my uro, if I should need further treatment in the future.
Posted 10/28/2013 9:50 AM (GMT -5)
I think this makes for a good case, that after a man receives a fresh PC dx, he should seek a good medical oncologist before discussing or choosing any primary treatment. Someone that doesn't have a dog in the fight. Someone that could be neutral.

It's only natural that a Surgical Uro will be biased toward surgery and a RO will be biased by RT. And as far as money goes, that is the nature of any business, medical or otherwise, to be profit driven and always watching the bottom line.

Even when I was a State Finance Director for the Mentally Disabled here in SC, we were a "non profit" in spirit, but was ran like a tight money grubbing business. What a normal biz calls profit, I had to call it "surplus", and what was really an operating loss, was now a "deficit". Same thing, different words. There was nothing non-profit in what we did. Every department, and every resident home we owned, all have their separate P&L (profit/loss) sheet, and each had to be profitable, oops, mean had to produce a surplus, on their own merits.

Will give my uro/surgeon credit, he never once hinted that surgery was better, and truly gave me a list of all available primary treatment options fairly represented, and then at another meeting, we went down the list one by one. I made the decision to have open surgery on my own.

David
Posted 10/28/2013 12:34 PM (GMT -5)
I second Tony's opinion about second opinions and referrals. Never get a 2nd opinion "in house" and never get a referral from the 1st opinion doctor.
My oncologist explained how referrals work. A Uro will often refer his older patients or more advanced patients to a radiologist and this is a stream of income for the radiologist. His real customer is the URO and not the patient. If he continues to offer a different opinion than the referring Uro, how long will it take for the Uro to stop referring patients to him? This is a built in conflict of interest that is best avoided by getting your own 2nd opinion from a doctor that has no financial relationship to the referring doctor.
Posted 11/2/2013 9:47 PM (GMT -5)
Hi Bohemond,

Thank you for sharing the info. I consulted recently with Dr. D'Amico at Dana-Farber/Brigham-Women to hear his opinion on ART versus SRT regarding my positive surgical margin. So I was wondering if you were his patient. I am consulting others to hear their opinions as well, but I would like to consult with someone who is an expert in the area but that does not have a stake in the treatment. It would be nice to communicate privately to hear your impressions, based in your experience. I could not find your e-mail in your profile, but my e-mail is in my profile.

All the best,

Joe.
Posted 11/2/2013 10:26 PM (GMT -5)
I don't know of any business that isn't in it for the money, why would the medical business be any different, now that we are long pass a 1950's America. Its gone folks. Caveat Emptor I don't know of any individual that works for nothing, ceptin saints. If any thing that is being done was "illegal" the avenues are there to address that. Personal responsibility and social responsibility are one coin, in spite of my poor syntax.
Posted 11/2/2013 11:18 PM (GMT -5)
FWIW, I know that these medical people are in it as a business. But, that said, I spent many years in business working for a Fortune 100 corporate America company, where my boss would send me in to clean up other people's messes--in addition to my other responsibilities -- with no bonuses or commission's for me other than doing what is right, backed by someone who trusted me to to get the job done with a reasonable settlement for our customer and my company. I think that there are many doctors who actually put their patients' best interests above their own paychecks--that there are people other than me (and my wife, and many of my friends) who put outcomes for others above our own personal bottom line.
Posted 11/3/2013 12:51 AM (GMT -5)
This is all true and realize I came off callous. I am trying to make the point, that no one should be surprised at this. Yes it is too bad that money is the driving force in todays society, but its been that way or moving that way for the las 50 to 60 years and it is becoming the more "accepted " practice and as new generations come along and see it every where, it will be worse before it gets better. It will change as this developing and sure paradigm exhausts itself and collapses under its own weight in ways that will not be pretty. I have much faith in the future of humanity, long term, short term, who can not see were we are heading. Not apocalyptic, but surely equal too, if not more than previous endpoints this planet has endured as the pendulum reaches its zenith.{ sideways, tee hee} Always with a progression toward better, I would add.
Posted 11/3/2013 9:27 AM (GMT -5)
This is old news, very well known, but certainly worth bringing up. It is an obvious conflict of interest and we need to be aware of this.

I also second the idea of having a medical TEAM. I've done that, with the idea that many brains are better than one. But it also mitigates against conflict of interest situations.

I have a super medical oncologist (Dr. Lam, in Marina del Rey, Ca). But I live in Michigan. So, I also see another top medical oncologist at Umich (Dr. Hussain). Both of them specialize only in PC. In addition I have a local medical oncologist who is willing to follow Dr. Lam's suggestions, a local urologist, and my family practice doctor.

One interesting and disturbing fact, for me. A few months ago, my liver enzymes suddenly shot up (both above the normal range and one was 5 times the upper limit). I immediately got a call from Dr. Lam's office (the next day, even before I picked up my results) and we stopped the Casodex. The disturbing part was that none of these other doctors (who I think are excellent) contacted me. This could have been a very serious -- even fatal --situation (if nobody contacted me). It was a sobering experience and underscores the fact that we need to get all test results and be our best advocates.

I should add that I did get a call from Dr. Hussain's office about 3 weeks later.

Incidentally, one of the biggest pains is making sure all members of my team receive my test results. My local lab takes down all that information, but continually messes up faxing the results to everyone. Very annoying.

Mel

Posted 11/3/2013 9:47 AM (GMT -5)
John T made a good point of selecting your own second/third opinion MD and not a referral by your own doctor(s). I had a second and third opinion by RO's in different cities with both being at a major universities before deciding on IMRT alone. Finally, I also had post IMRT follow-up by a medical oncologist (should have done at start) recommended by friend and patient to oversee periodic testing and HT.

Robert
Posted 11/3/2013 10:52 AM (GMT -5)
We are conflating two issues here. Yes, one should get second opinions from a financially (and socially) independent practices. Good idea. Keeps the doctors honest and on their toes.

On the other hand, the problem that a urologist becomes more open to suggesting radiation treatments when his practice invites a radiation guy to join (with the concurrent investment that entrails) is a different matter. Given the usual slant of discussions on this forum lately, how horrible is that, really?
Posted 11/3/2013 12:32 PM (GMT -5)
Peter:

I have no idea what you mean by your last sentence

Mel

Posted 11/3/2013 4:09 PM (GMT -5)
Mel,

When discussing urologists on this forum the conventional wisdom seems to be that they are biased to recommend surgery as a primary treatment. This is because surgery is what they do -- it's how they look at the world. (I understand that this is a somewhat recent development here and that several years ago the forum was rather more pro-surgery than it is now.) The article suggests that when urologists' practices buy radiation equipment, that makes them more likely to recommend radiation for some of their patients.

My question is, leaving aside the uncomfortable issue of changes in doctors medical recommendations that appear to be driven by their financial incentives, might their patients not benefit from the lessening of the surgeon's pro-surgical biases? If we think that urologists are too quick to recommend surgery, why are we upset that they have found a way to recommend radiation more often?
Posted 11/3/2013 4:45 PM (GMT -5)
PDA,

The problem is not that they recommend what they devote their lives to and get their income stream from -- we expect that, don't we? The conflict arises because when they have equity in a radiation treatment facility, they only recommend the most expensive and profitable form of radiation (IMRT) that has no advantage for the patient over other kinds of RT (SBRT, HDR & LDR brachy), or Active Surveillance, which is the therapy with the lowest cost and least SEs and is suitable for the majority of their patients.

- Allen
Posted 11/3/2013 5:51 PM (GMT -5)
Peter:

It's a concern when a doctor has a huge financial interest in any specific form of tx.

Ideally, we would like a doctor to recommend what he/she thinks is the best available tx. for us.

Now probably a urologist is partial to surgery because he is a surgeon. Might as well believe in your modality.

But this new development isn't even a question of believing in a certain form of tx. It is purely a financial incentive.

Big concern for the patient, methinks

Mel

Posted 11/3/2013 8:43 PM (GMT -5)
a lot of urologists have facilities where they perform biopsies too. By law, at least here, they have to disclose this when suggesting you have a biopsy.

this argument pops up form time to time. There might be a few greedy unethical doctors, but I prefer to assume that like all Americans they like to earn money and that they truly believe in the specialty/profession they have chosen and worked so hard to achieve.
Posted 11/4/2013 6:29 AM (GMT -5)
I work for pay. No shame in that. As I was wheeled into the operating room I was amazed at the complexity I saw along with the efficiency of the movements of the many people in the room, who seemed to me to be a well- oiled machine. I thought, only the free-market could have done this. Everyone from the equipment manufacturers to the doctors and nurses had worked incredibly hard, devoting years of their lives, to be able to do this complex procedure with precision and consistency. In my experience, doctors don't become doctors just for the money. It's too hard. These are all very bright people who, if money were their sole motivator, could find an easier path. On the other hand, knowing that the free market will amply reward them, if they make it, is nice to know as they work to perfect their crafts so that patients will be clamoring for their services and they can maximize their return. And most people I see on this forum discuss the CHOICES they had of treatment and doctors. The fact that we have a choice leads to excellence in care as they compete for our business by building an excellent reputation. A FANTASTIC part of this forum is educating us on how to make informed choices. It is the UNINFORMED who might get pushed by doctors, whose reputation is not yet established, toward the treatment that gets them them the money to pay for their equipment and the PRACTICE to build their reputations. I don't blame those doctors for their eagerness. I suppose we need the "uninformed" so new doctors can build their skill, but I hope the guys who make it to this forum are not among those uninformed!
Mikey
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